Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy

D M D Özdemir-van Brunschot, A E Braat, M F P van der Jagt, G J Scheffer, C H Martini, J F Langenhuijsen, R E Dam, V A Huurman, D Lam, F C d'Ancona, A Dahan, M C Warlé, D M D Özdemir-van Brunschot, A E Braat, M F P van der Jagt, G J Scheffer, C H Martini, J F Langenhuijsen, R E Dam, V A Huurman, D Lam, F C d'Ancona, A Dahan, M C Warlé

Abstract

Background: Evidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption. A lower insufflation pressure may hamper visibility and working space. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP.

Methods: This study was a blinded randomized controlled multicenter trial. 34 kidney donors scheduled for laparoscopic donor nephrectomy randomly received low-pressure PNP (6 mmHg) with either deep (PTC 1-5) or moderate NMB (TOF 0-1). In case of insufficient surgical conditions, the insufflation pressure was increased stepwise. Surgical conditions were rated by the Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor) to 5 (optimal).

Results: Mean surgical conditions were significantly better for patients allocated to a deep NMB (SRS 4.5 versus 4.0; p < 0.01). The final insufflation pressure was 7.7 mmHg in patients with deep NMB as compared to 9.1 mmHg with moderate NMB (p = 0.19). The cumulative opiate consumption during the first 48 h was significantly lower in patients receiving deep NMB, while postoperative pain scores were similar. In four patients allocated to a moderate NMB, a significant intraoperative complication occurred, and in two of these patients a conversion to an open procedure was required.

Conclusions: Our data show that deep NMB facilitates the use of low-pressure PNP during laparoscopic donor nephrectomy by improving the quality of the surgical field. The relatively high incidence of intraoperative complications indicates that the use of low pressure with moderate NMB may compromise safety during LDN. Clinicaltrials.gov identifier: NCT 02602964.

Trial registration: ClinicalTrials.gov NCT02602964.

Keywords: Deep neuromuscular block; Laparoscopic donor nephrectomy; Laparoscopy; Low-pressure pneumoperitoneum; Pneumoperitoneum.

Conflict of interest statement

Prof.dr. A. Dahan and dr. M.C. Warlé received grants from Merck Sharp and Dohme for investigator-driven studies unrelated to this study. Mrs. D. Özdemir- van Brunschot, dr. A.E. Braat, Mr. M.F. van der Jagt, prof.dr. G.J. Scheffer, dr. C.H. Martini, dr. J.F. Langenhuijsen, Mrs. R.E. Dam, dr. V.A. Huurman, dr. D. Lam, and dr. F.C. d’Ancona have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Study flow chart

References

    1. Wilson CH, Bhatti AA, Rix DA, Soomro NA. Comparison of laparoscopic and open donor nephrectomy: UK experience. BJU Int. 2005;95(1):131–135. doi: 10.1111/j.1464-410X.2004.05264.x.
    1. Kok NF, Lind MY, Hansson BM, Pilzecker D, Mertens zur Borg IR, Knipscheer BC, et al. Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial. BMJ. 2006;333(7561):221. doi: 10.1136/bmj.38886.618947.7C.
    1. Fonouni H, Mehrabi A, Golriz M, Zeier M, Muller-Stich BP, Schemmer P, et al. Comparison of the laparoscopic versus open live donor nephrectomy: an overview of surgical complications and outcome. Langenbeck’s Arch Surg. 2014;399(5):543–551. doi: 10.1007/s00423-014-1196-4.
    1. Ozdemir-van Brunschot DM, Koning GG, van Laarhoven KC, Ergun M, van Horne SB, Rovers MM, et al. A comparison of technique modifications in laparoscopic donor nephrectomy: a systematic review and meta-analysis. PloS ONE. 2015;10(3):e0121131. doi: 10.1371/journal.pone.0121131.
    1. Freeman L, Rahmani EY, Burgess RC, Al-Haddad M, Selzer DJ, Sherman S, et al. Evaluation of the learning curve for natural orifice transluminal endoscopic surgery: bilateral ovariectomy in dogs. Vet Surg. 2011;40(2):140–150. doi: 10.1111/j.1532-950X.2010.00779.x.
    1. Autorino R, Cadeddu JA, Desai MM, Gettman M, Gill IS, Kavoussi LR, et al. Laparoendoscopic single-site and natural orifice transluminal endoscopic surgery in urology: a critical analysis of the literature. Eur Urol. 2011;59(1):26–45. doi: 10.1016/j.eururo.2010.08.030.
    1. Carus T. Current advances in single-port laparoscopic surgery. Langenbeck’s Arch Surg. 2013;398(7):925–929. doi: 10.1007/s00423-013-1113-2.
    1. Borle FR, Mehra B, Ranjan Singh A. Comparison of cosmetic outcome between single-incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy in rural indian population: a randomized clinical trial. Indian J Surg. 2015;77(Suppl 3):877–880. doi: 10.1007/s12262-014-1044-3.
    1. Gurusamy KS, Samraj K, Davidson BR. Low-pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2009
    1. Ozdemir-van Brunschot DM, van Laarhoven KC, Scheffer GJ, Pouwels S, Wever KE, Warle MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc. 2015;30(5):2049–2065. doi: 10.1007/s00464-015-4454-9.
    1. Warle MC, Berkers AW, Langenhuijsen JF, van der Jagt MF, Dooper PM, Kloke HJ, et al. Low-pressure pneumoperitoneum during laparoscopic donor nephrectomy to optimize live donors’ comfort. Clin Transplant. 2013;27(4):E478–E483. doi: 10.1111/ctr.12143.
    1. Singla S, Mittal G, Raghav Mittal RK. Pain management after laparoscopic cholecystectomy-a randomized prospective trial of low-pressure and standard pressure pneumoperitoneum. J Clin Diagn Res. 2014;8(2):92–94.
    1. Kim MH, Lee KY, Lee KY, Min BS, Yoo YC. Maintaining optimal surgical conditions with low insufflation pressures is possible with deep neuromuscular blockade during laparoscopic colorectal surgery: a prospective, randomized, double-blind, parallel-group clinical trial. Medicine. 2016;95(9):e2920. doi: 10.1097/MD.0000000000002920.
    1. Staehr-Rye AK, Rasmussen LS, Rosenberg J, Juul P, Lindekaer AL, Riber C, et al. Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study. Anesth Analg. 2014;119(5):1084–1092. doi: 10.1213/ANE.0000000000000316.
    1. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth. 2014;112(3):498–505. doi: 10.1093/bja/aet377.
    1. Boon M, Martini C, Hellinga M, Bevers R, Aarts L, Dahan A (2016) Influence of variations in arterial PCO2 on surgical conditions during laparoscopic retroperitoneal surgery. Br J Anaesth 117(1):59–65. doi:10.1093/bja/aew114
    1. Madsen MV, Istre O, Staehr-Rye AK, Springborg HH, Rosenberg J, Lund J, et al. Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: a randomised controlled trial. Eur J Anaesthesiol. 2016;33(5):341–347. doi: 10.1097/EJA.0000000000000360.
    1. Bruintjes MH, van Helden EV, Braat AE, Dahan A, Scheffer GJ, van Laarhoven CJ et al (2017) Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis. Br J Anaesth 118(6):834–842. doi:10.1093/bja/aex116
    1. van den Bussche EDB, Feryn T, Mulier JP. Effect of muscle relaxants on the abdominal pressure volume relation in bariatric laparoscopic surgery. Surg Endosc. 2007;21:S215.

Source: PubMed

Sponzoři a spolupracovníci

Zdravotní podmínky

Drogové intervence

3
Předplatit